Telehealth: a tool for the 21st century (PPT)
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Telehealth: a tool for the 21st century (PPT)

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    Telehealth: a tool for the 21st century (PPT) Telehealth: a tool for the 21st century (PPT) Presentation Transcript

    • Telehealth: A tool for the 21 st century Karen S. Rheuban MD Professor of Pediatrics Medical Director, Telemedicine University of Virginia
    • Disclosure
      • I have no financial relationships to report that would create any conflict of interest in relationship to this presentation
    • Objectives
      • Understand the applications of telemedicine in the delivery of healthcare, especially as they relate to children
      • Understand statutory and regulatory issues impacting the development of telemedicine networks
    • Definitions
      • “ Telemedicine” is the use of medical information exchanged from one site to another via electronic communications to support
            • Medical diagnosis
            • Ongoing patient care
            • Remote patient monitoring
        • “ Telehealth” encompasses a broader definition of remote healthcare that does not always involve clinical services
            • Health-related distance learning
    • Telemedicine: History
      • Alexander Graham Bell
      • Hugo Gernsback (vision)
      • Massachusetts General
      • U of Nebraska
      • NASA
      • Dept of Defense
      • University of Virginia
    • Mission
      • Facilitate the Health System’s missions of
              • Clinical Care
              • Teaching
              • Research
              • Public Service
    • Services
      • Videoconferencing for patient care
      • Store and forward applications
      • Distance learning
              • health professionals
              • patients
              • students
    • UVA Specialty/Subspecialty Participants
      • Cardiology
      • Dermatology
      • Diabetes
      • Emergency Medicine
      • Endocrine
      • ENT
      • Gastroenterology
      • Genetics
      • Geriatrics
      • Gynecology
      • Hematology
      • Infectious Disease
      • Nephrology
      • Neurology
      • Neurosurgery
      • Ophthalmology
      • Orthopedics
      Obesity Oncology/Tumor boards Pain management Pediatric cardiology Pediatric nephrology Pediatric oncology Plastic surgery Psychiatry Pulmonary medicine Radiology Rheumatology Surgery TCV Toxicology/Poison control Urology Wound care
    • Partnerships
      • Academic-community hospital linkages
      • Academic-academic hospital linkages
      • Rural clinics (FQHCs, Veteran’s clinics)
      • Virginia Department of Health
      • Virginia Department of Corrections
      • School health
      • Nursing home
      • Home telehealth
    • Barriers to Access
      • Geographic
        • >20% of US population reside in rural areas
        • Burden of transportation to care generally borne by patients
        • Medicaid programs bear the burden of transportation costs
          • 1999: >$50 million/year in Virginia alone
        • Multiple definitions of rural
      • Financial
        • The uninsured, underinsured (> 40 million uninsured)
        • Delayed access to services for uninsured
        • High cost of travel for locally unavailable specialty care
    • Barriers to Access
      • Societal
        • Societal stigmatization
        • Cultural barriers
        • Language barriers
      • Maldistribution/shortage of providers
        • Predicted shortage of physicians 85,000-200,000 by 2020
        • Urban predominance of specialty providers
        • Isolation of rural health providers
        • Need for continuing health professional education
    • Benefits of telehealth
      • Patients :
        • Timely access to locally unavailable services
        • Spared burden and cost of transportation
        • Improvement in quality of care
      • Health professionals
        • Access to consultative services
        • Access to CME
        • Primary care oversight of patient care
      • Rural communities
        • Enhanced healthcare/economic empowerment
    •  
    •  
    • Patients served: UVA program
      • >15,000 patient encounters
      • >30,000 teleradiology readings
      • Services in >30 different specialties
        • Emergency
        • Urgent
        • Single consults
        • Block scheduled clinics
        • Screenings with store forward technologies
          • New mobile digital mammography van
          • Retinopathy
    • More than technology and numbers: Saving lives: Infant with Interrupted aortic arch
    • More than technology and numbers: Facilitating expert care
    • Enhancing access
    • Educational programs
      • Broadcast continuing health professional education
      • UME, GME
      • Patient education
      • School Health Projects
    • International humanitarian outreach Swinfen Charitable Trust
      • In conjunction with the Center for Online Health in Brisbane
      • Automated email consultation system
      • Physician to physician consults with attached digital images
      • Volunteer consultants in 59 subspecialties, 1479 cases
      • Consults from:
    • Pre/perinatal care ANGELS program - Arkansas
      • Antenatal Neonatal Guidelines, Education and Learning System
        • University of Arkansas/Medicaid partnership
        • Increase prenatal screening and referrals
        • Genetic counseling, targeted ultrasounds, MFM consultations, pediatric consultations
        • Outcomes
          • 2 year period – 467 congenital malformations
          • 50% referred for delivery
          • No-show rate for TM clinics 12%, UAMS 20%
          • Shannon Barringer, UAMS – Presentation Pediatric Telehealth Colloquium, 9/07
    • Tele-ophthalmology
      • Tele-ophthalmology technologies: live or store forward
        • Most data in patients with diabetes
        • Retinopathy of prematurity
      • ATA: Tele-ophthalmology standards
    • Pediatric cardiology
      • Incidence of CHD is 8/1000 live births
      • Traditional models of care:
        • Schedule appointment
        • Emergency transfer
        • Wait for field clinic
        • Obtain echo and mail, courier
      • Models for tele-echocardiography
        • Live interactive support of remotely located technologists
        • Store forward images sent in digital format
    • Acute stroke intervention
      • Challenge of lack of access to stroke neurologist in rural areas
      • Time is of the essence (3 hour window for thrombolytic agents
      • Increase use of TPA in rural hospitals from 4% to 23%
    • HIV/AIDS
        • Outcomes: UVA Telehealth HIV Program 1
          • 213 correctional patients treated with 1812 visits over 5 year period
          • Of patients naïve to therapy:
            • 77% attained undetectable viral load (<50 copies/ml)
            • 50-60% in HIV clinic
            • 40% receiving community based care by non-HIV specialists
        • 1 Rheuban,KS, Wispelwey B et al HIV/AIDS, HRSA Telemedicine Technical Assistance Documents 2004
    • Cancer outreach: Mobile digital mammography
    • Tele-pathology
      • Primary interpretation
      • Second opinion
      • Collaborative tumor boards
      • Remote access to clinical trials
    • Tele-mental health
      • Shortage of mental health providers in rural areas
      • Consultations, medication management
      • Sign language for hearing impaired
      • Interpreter services
    • Tele-mental health
      • Comprehensive review of the medical literature in telepsychiatry 1
        • Technology predominantly interactive videoconferencing
        • Improve access, shorter wait times
        • High rates of patient satisfaction in all age groups
        • Diagnosis change from PC provider diagnosis in 91%
        • Medication changes in 57%
        • Reduced geriatric hospital admissions from long-term care facility by 59%
        • 1 Hilty, D, et al, Can J Psych 2004; 49:12-23
    • e-ICU
      • Models for support of intensive care units 1
        • Two adult ICUs in large tertiary care hospital system
        • 2140 patients receiving ICU care
        • E-ICU services from 12 noon – 7am
        • Program utilized off-site intensivists, physician extenders, electronic data display, decision support tools
        • Results:
        • Hospital mortality decreased from 12.9-9.4%
        • ICU length of stay shorter 4.35-3.63 days
        • 1 Breslow, MJ, Crit Care Med 2004 32(1): 31-38
    • Remote monitoring and Home telehealth
            • Remote monitoring
              • CHF
              • Diabetes
              • COPD/ Asthma
    • Challenges
      • Funding of telehealth (Stark, Anti-kickback Laws)
      • Reimbursement
      • Outcomes
      • Confidentiality
      • JCAHO
      • Licensure
      • Malpractice
      • Telecommunications venue/costs
      • Integration with EMRS/RHIOS
      • Interagency alignment related to policies
        • Federal (definition of rural, rural vs urban)
        • State (eligible plans, coverage of store and forward)
    • Outcomes:2006 Agency for Healthcare Research and Quality (AHRQ)
        • Still significant gaps in the evidence base between where telemedicine is used and where its use is supported by high-quality evidence.
        • Further well-designed and targeted research that provides high-quality data will provide a strong contribution to understanding how best to deploy technological resources in health care.
      Hersh, W, Supplement. Telemedicine for the Medicare Population: AHRQ Evidence Report/Technology Assessment Number 24, Supplement, 2006
    • Virginia Telehealth Network
      • Multi-institution/organization collaboration initiated by Virginia Department of Health
      • Inventory current activities
      • Increase awareness of telehealth
      • Increase collaboration
      • Secure funding – competitive grants, appropriations
      • Advocate in support of critical policy issues
    • The future of telehealth
      • Outcomes
      • Standards
      • Demonstration projects (ARRA)
      • Integration into mainstream medicine
      • Collaboration amongst providers, policymakers, regulators
      • Champions at all levels
      • Engage your legislators!!!
    • Champions Congressman Rick Boucher, Mrs. Lisa Hubbard, Alexandra Bartley
    •